Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 1
1 March 2, 1998. Acadia Institute Study of bioethics in American Society. Interview #4 2 with Arthur L. Caplan, Ph.D., Director, Center for Bioethics, Trustee Professor of 3 Bioethics, and Chief, Division of Bioethics, University of Pennsylvania. The interview is 4 being conducted by Dr. Renee C. Fox, and Dr. Carla Messikomer, in Dr. Fox's apartment 5 in Philadelphia.
6 FOX: What was the trajectory of your career at Hastings? You couldn't have gone any
7 further than you went, other than becoming Daniel Callahan himself. So how
8 many years was that all told?
9 CAPLAN: Seven.
10 FOX: Maybe in recounting a little bit your own involvements over those seven years
11 you'll be telling us some things about what was going on at Hastings during that
12 time.
13 CAPLAN: When I say seven, by the way, I am dating that from the time I really was hired as
14 a real staff person. I was there earlier than that as a research assistant, helper,
15 gopher....
16 FOX: Yes, that's where we left you last time.
17 CAPLAN: I think I told you I was in the second phase of my unethical career. The first one
18 was being a mock medical student. The second was being a post-doc before I was
19 a doc. So I had been there for a year as a post-doc. I'd been there probably in
20 1974 to 1977 as a kind of research assistant type person, very part-time. That's
21 when these things are taking place. Then in 1977-78 I get hired, really put on the
22 faculty. Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 2
23 FOX: How did that happen?
24 CAPLAN: Well, it's funny, what really got me hired to was the fact that I seemed to know a
25 lot about genetics. There was a genetics project, an early one at Hastings, had
26 people like John Fletcher, Bob Murray, Marc Lappe, Tabitha Powledge, Alex
27 Capron, on it. I laugh sometimes now when I hear some of the discussion of
28 genetic testing and screening, which acts as if no one ever thought about this.
29 These were early discussions of sickle cell and Tay-Sachs large scale screening
30 and the issues involved, and all the issues were there. Stigmatizing populations,
31 could you get informed consent, did people understand the difference between
32 disease and trait...and on and on. Everything was there. And Hastings ultimately
33 issued a very important document, which I can't remember if I mentioned last
34 time, which was the first ethical guidelines about genetic screening. What was
35 interesting about it wasn't that there were guidelines; it was interesting that it was
36 a Hastings Center group that got into The New En�land Journal and declared
37 guidelines, which was a kind of sociological moment of some interest. It's as if I
38 sat in the room and issued the Art Caplan guidelines, it was like who cares. But
39 clearly Hastings had gotten to the point where a distinguished group would be
40 treated as a serious, blue ribbon panel, or some body of authority and the Journal
41 published their guidelines. That was very interesting for me to watch. I can't say
42 at the time that I was so self-aware of its importance, but I was dimly aware, and it Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 3
43 certainly was important looking back on it now.
44 FOX: A very important step in institutionalizing bioethics.
45 CAPLAN: Exactly. It was like Rothman sees Beecher in the 1966 article; the Hastings
46 guidelines was a very important moment in the emergence of non-medically
47 driven bioethics. Here was an interdisciplinary group from a non-medical
48 institution in the leading medical journal publishing on a topic that everybody
49 would have said is something that the geneticists should have done. All that was
50 as interesting; it's as seminal in its way as Beecher's clinical research article
51 because it's saying that all these features are coming together, pay attention to
52 this. Getting baptized almost as a legitimate thing. So that was one of the
53 projects that I helped to staff or do a lot of the scut work. I helped write those
54 guidelines. I would say that Marc Lappe and Tammy Powledge, who were on the
55 staff, did more but I helped them. That was really what got me hired. They knew
56 me pretty well because they had seem me for a couple of years. They had me as a
57 post-doc. I thinkthere was a lot of sentiment. Ruth Macklin would tell you that
58 she wanted to keep me around, and that sort of thing. But it was really the
59 genetics stuff which I seemed to know better, and everybody thought, "Well,
60 genetics is going to have a big future in bioethics." Which it did. Although it's
61 interesting, it dipped. I don't know why it dipped. I have a feeling that there was a
62 little bit of boom and bust, not in the ethics but in the genetics end, that tests were Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 4
63 expected to flowafter Tay-Sachs and sickle cell, and didn't. And then it was only
64 the genome mapping project that really got things going in a way that allowed for
65 more disease identification. So I think part of it was that the science stalled, not
66 the ethics.
67 FOX: By and large though, though this is somewhat editorializing, my sense is that
68 bioethicists tended to be more reactive to what developed rather than to go
69 forward and say, "We must continue to work in the genetics area because this is
70 critical."
71 CAPLAN: Some people tried. There were efforts even at that time, in the early '80's, to have
72 a discussion in this genetics group of something hilarious... cloning. We did try.
73 Will Gaylin and I went to every foundation imaginable, one on one. Will knew
74 everybody and we tried to get support for a follow-up project for the genetics
75 group on cloning. And everybody said, "It's science fiction, it's ridiculous, there
76 is no need to do it." So there was no institutional willingness to support
77 something that wasn't real. Plus, to be honest, my impression, was that the
78 scientificcommunity was not willing to tolerate a cloning discussion because it
79 looked too threatening. Remember, subsequent to that there had been a lot of
80 pronouncements about "we will never do germ line engineering," and there were a
81 fair number of pronouncements that we would never do cloning too. But I think
82 these are all defensive, I don't believe any of them for a minute. This idea that Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page S
83 you wouldn't do germ line genetic engineering, change sperm and eggs, is
84 crazy ... of course you would if you could fix some diseases. You'd absolutely do
85 it. You'd be an idiot not to do it. So what are they talking about? What they
86 mean is we're not going to be eugenecists, we're not going to be Nazis, we're not
87 going to be....
88 FOX: Where was the recombinant DNA controversy?
89 CAPLAN: That comes in the late 1970's, it's about 1978 to about 1981. And Asilomar must
90 be in there about 1981 , something like that. Did that divert some attention? Yes,
91 and there was one other thing that was going on there too that you'll remember, it
92 was the criminal chromosome fightand the sociobiology and IQ fightingthat was
93 going on at this time. So there were things that were diverting attention away
94 fromthe--let's call it--atoms-for-peace approach to genetics, which was
95 "everything is good and we'll fight diseases, and this will be helpful and will
96 prevent the birth of people with problems." Over to: "Gosh, genetics could be
97 controversial, you might stereotype people." Or maybe it's an attempt to foist
98 eugenic visions on the population, that's what the IQ and the sociobiology debates
99 were about. In fact, a little side note: since we're doing some kind of a history, I
100 was told firmlyby my graduate advisor, ErnstNag el, that I was a fool to spend
101 any time putting together the sociobiology book, which was my first book. Could
102 not take time off from the thesis. I never told him I was doing it, but I did it Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 6
103 anyway. It's the biggest selling book I ever wrote! It was like, his intuition is
104 wrong about this! I know, I know, you've got to finish your thesis, I get that. But
105 it was like, this is an opportunity and ifl miss it.. .l know about the biology, I
106 understand the philosophy and this isn't coming back. So it's either do it now or
107 forget it. So I never told him. I wrote it like in secret, he's say, "Are you doing
108 that book?" And I would say, "No ... no." (Laughter) And that is why I was a post-
109 doc before I was a doc because it cost me a year. This is like, things you'd never
110 tell your children to do. I'd never tell any graduate student to do this. So genetics
111 dominates the early scene.
112 FOX: So now you're starting as a regular full-timeperson at Hastings.
113 CAPLAN: A couple of other comments about bioethics, just at this sort of transition period
114 from the 1970's to '80's. I commented that when I came to Hastings I'd seen or
115 been in contact with many of the founders of the field, and I have said that many
116 of them came fromreligious backgrounds. Just about the time I'm arriving, say in
117 this period as a full-time, real staff person, 1978 to 1984, this is really the age of
118 the philosophers in bioethics. Probably a wonderful project for looking at how
119 this went is to look at something that Hastings published called The Foundations
120 of Ethics Series, which was four volumes, and they are hard to find because they
121 were never picked up by a commercial publisher. Hastings had enough clout to
122 get it's guidelines into The New En!jland Journal, but it did not yet have enough Arthur Cap lan Acadia Institute St udy of Bioethics in American So ciety page 7
123 clout to get the commercial university presses to take anything it was doing
124 seriously. So it had these wonderful books, a four partseries that was based on
125 seminars that took place at the Center over a period of four years, and with people
126 like Alistair Mcintyre, Charles Fried, James Gustafson, Paul Ramsey, and on and
127 on and on. All these people are blathering away about the nature of the
128 relationship between ethical theory and bioethics. This is interesting for a couple
129 of reasons. One : the foundational question like that is almost never asked about
130 bioethics today. Two: when I talk about the relationship between social science
131 and bioethics today, the relationship of ethical theory to bioethics was its
132 equivalent back in this earlier period of the late 1970's. Th e reason it was so
133 important, though, was because the philosophers had arrived and were trying to
134 wrestle with how did bioethics fitin to ethics, or philosophy. And the books are
135 funto look at; I have them at home. You'll see in them some attempt to beat up
136 religion by the philosophers and say that isn't the base of ethics, it won't work.
137 You' 11 see some people looking for theory to ground ethics. There's a paper that's
138 very interesting by Mcintyre, which is sort of a forerunner of a lot of his
139 philosophy writings. It says, "B ioethics won't work unless it's grounded in a
140 community. Bioethics won't work unless it's grounded in virtues that people
141 have consensus about." Later he decides that's impossible and so bioethics is
142 stupid, and he gets out of the whole thing. He spawns people like Ezekiel Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page S
143 Emmanuel and Troy Brennan at Harvard, who subsequently write books in the
144 '90's about sort of the role of community and how bioethics goes. But the point of
145 this little saga is, in this era philosophy is attempting to grapple with bioethics, it's
146 trying to get hegemony over religion and at the same time is not paying any
147 attention to social science or empirical things because philosophy at that time
148 never did; it still may not today but it certainly wasn't then. You have to think of
149 this as the heyday of moral philosophy. We're talking about the era of Rawls and
150 Nozick, we're talking about these books that are appearing. People are taking
151 philosophy very seriously and ethics has never had it so good, not that it was
152 great, but this was like as hot as it gets for a field like ethics in philosophy. Two
153 main books, big battles going on, people in politics taking seriously, the fight
154 between Rawls as a liberal and Nozick as a conservative. Nozick, I think as much
155 as Milton Friedman, gives birth to the Republican revolution, to tell you the truth.
156 Nozick himself is interested by that absolute nut Ann Rand, which makes me
157 quiver every time I think about how she's had her bony little hand reach out and
158 shape .. .! mean Greenspan is a Randian today and influencedstrongly by Nozick.
159 FOX: When you say the politics, who is taking sides?
160 CAPLAN: Republican thinkers. Conservative revolution right in this period. This is when
161 James Wilson, Sam Huntington at Harvard, lots and lots of people are taking
162 Nozick very seriously. As much as Milton Friedman is pressing a case in Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 9
163 Chicago.
164 FOX: Do you mean political science or do you mean Washington?
165 CAPLAN: I mean both. And the liberals are rallying around Rawls. So it's never been so
166 much funin ethics, at least in my life time, real battles, ideological battles,
167 fundamentaldifferences. That's partof the reason why when Renee Fox shows
168 up, or others in the early '80's, and says, "How come no one cares about context?"
169 It's the wrong question. The battle is, what are the roots philosophically for
170 bioethics in philosophy? And can you get rid of this burden of religion?
171 FOX: Let's go back a minute to the burden of religion. I see the presence on the
172 bieothics scene in this era when you first became associated with Hastings, of
173 religionists like Gustafson and Ramsey and the great respect they were accorded. I
174 see no evidence that their perspective had any influence on the framework of
175 bioethical thinking, except you're saying the framework was forged after that. Is
176 that what you're saying?
177 CAPLAN: Right. The only way you could see it is if you pulled away the stained glass of
178 what the philosophy frameworkimposed. You'd see it if you went back before
179 then. If you look at the literature in the mid '70's in The Hastings Center Report it
180 looks very different. Once the philosophical secular revolution occurs, in my
181 view, I don't think religion disappears; it's like the Communist party trying to
182 suppress the Greek Orthodox Church or something. It doesn't disappear, it just Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 10
183 sort of runs in differentplaces. It may move over to seminaries; the dialogue
184 stops with the Hastings Center; it may happen more at the Kennedy Institute. It
185 may go underground so to speak, with people kind of attacking the philosophical
186 thing, dishonestly saying, "It's missing the religious or spiritual element." No one
187 will say that because no one will listen to them, but they are talking that way.
188 Leon Kass becomes a fighter for a certain religious point of view that he winds up
189 presenting in romantic biology terms because it's almost an embarrassment to sit
190 there and say, "You mean Judeo-Christianity has nothing to say about any of this
191 stuff?" So he's an example of trying to fightthat war.
192 FOX: But the picture of there being a religious era that preceded this is not quite right. I
193 think it's conflated. Although people esteemed Paul Ramsey's or Jim Gustafson's
194 thinking, Jim probably because he taught so many people who were philosophers
195 and theologians who are among the founding generation, I never thought that the
196 conceptual framework of bioethics had melded.
197 CAPLAN: Well, I'd fight with you about it in this way. I think in the late 60's, early '70's the
198 framework of issues in bioethics is very much set by a key person, Paul Ramsey.
199 It may be hard to see him as a giant today, but he was then. The frameworks he
200 set out for thinking about genetic engineering or transplant are very much
201 religious. They're not Protestantly labeled but he's wrestling with what I would
202 call Christian responses to these technological advances. His books, The Arthur Caplan Acadia Institute St udy of Bioethics in American Society page 11
203 Perfectabilityof Man, and The Patient as Person, talk religious talk. For me, he's
204 the cutting edge guy. McCormick a little bit less so, but an important figurestill.
205 Not as good but very prolific, shaped a lot of debate. Remember that fightthey
206 had, McCormick and Ramsey, about research on children. That's a very
207 important debate and it was in The Hastings Report. I read it, it stuck with me a
208 long time. It was a debate almost about what are children, and what are we
209 supposed to expect from them, and what can we do to them, and why are we
210 altruistic? I don't want to say they're not philosophical, that's not fair, but the
211 way you got to that was by coming from religiously driven views of human
212 beings. So that's my kind of evidence for the claim that there is this era where, if
213 not an explicit religious framework, then at least religiously derived concepts and
214 religiously derived paradigms shape a lot of the bioethics conceptual taxonomy.
215 Then I thinkthe philosophical stuff replaces it. And I'm being a little crude
216 because it wasn't like there were no philosophers.
217 FOX: I guess that's what has gotten me confused. Th e codification of the conceptual
218 framework of bioethics was done by the philosophers. Whereas, this was more
219 informal in a way.
220 CAPLAN: Articles .. .looser ...there's no program. By the time the philosophers arrive you are
221 starting to see programs teaching, so the philosophy stuff is the stuffthat gets
222 taught. The battle about theory versus practice is very meaningfulto younger Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 12
223 philosophers coming into the field like John Aras, me, Jonathan Moreno. We're
224 not worried about "where is religion?" We're worried about "are we going to be
225 accepted in the field of philosophy if we do this codification." That first
226 Encyclopedia ofBioethics, it's looking like it's under the purview of Warren
227 Reich, theologian, but in fact the advisory board and the framework is very
228 philosophical. That's probably a codificationof the philosophical approach,
229 autonomy and freedomsand the three Georgetown mantra-like principles that
230 Tom Beauchamp and Childress codified, that's the appearance of the Principles of
231 Biomedical Ethics, that is a straight up philosophical conception. But before that
232 there's not nothing.
233 FOX: I was there at some of the firstmeetings for The Encyclopedia. The strange thing
234 about The Encyclopedia was that the problem was not what should go into The
235 Encyclopedia, the problem was what was bioethics? They had to sit there and say,
236 "What is bioethics?" The Encyclopedia codified the fieldbut The Encyclopedia
237 preceded ....
238 CAPLAN: Who got the defining article in defining bioethics? Do you remember? Dan
239 Clouser. So that is very philosophical, in fact it's a Bernie Gert-type of approach
240 to what bioethics is. But he got key article, "What is Bioethics?" So the
241 philosophers win, if you want to say what the institutional landmarks are for
242 definingthe nature of the field. They control The Encyclopedia, they control the Arthur Cap lan Acadia Institute St udy of Bioethics in American So ciety page 13
243 defining article, they control the defining textbook. The Principles of Biomedical
244 Ethics is the defining textbook. And even at Georgetown with its obvious
245 religious links, when Beauchamp and Childress do it, they do it as philosophy not
246 as religion. I think this is like a Paul Starr-type question about the social
247 transformation of American medicine; how did philosophy get in the drivers seat
248 when religion was there? Religion, of course, never firmly had its grasp on the
249 wheel because ....
250 FOX: That's what I've objected to, because then it sounds as if there was this religious
251 powerhouse and then they got somehow ....
252 CAPLAN: No , I'd say a loose amalgam, not a single powerhouse. They had their own
253 troubles because they came from differentreligious perspectives, so they brought
254 along all that baggage with them. The Catholics andthe Protestants are still kind
255 of gritting their teeth at one another.
256 FOX: My sense of the time is that there was a certain kind of--maybe this is in terms of
257 the institutionalization of the field--highrespect for certain giant figures, like
258 Hans Jonas, like Dhobshasky, like Paul Ramsey, however difficult it was to listen
259 to him speak, like Jim Gustafson. I suppose you could say that is more like a
260 charismatic forum, that they did not have a shaping influence on a paradigm.
261 CAPLAN: They didn't, but I'll go with this. It's a quilt model; I mean they are weaving
262 threads back and forth but a lot of them are drawing on spiritual and religious Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 14
263 traditions, that's my point. It's not a single model, it's certainly not even an
264 ideology, but they're pulling their ways of seeing things out of spiritual and
265 religious outlooks.
266 FOX: But for example, that period also was more compatible with a certain social
267 perspective.
268 CAPLAN: Sure.
269 FOX: For example, Jim Gustafson's a very special case because actually he comes out
270 of the Protestant social ethics tradition as well as the theological; his brother is a
271 sociologist. But basically their existential outlook included a sense of the
272 connection between individuals.
273 CAPLAN: We ll, philosophy appears though, in its heyday and Hans Jonas to the mainstream
274 of philosophy is a nut. He doesn't come from the right tradition, he comes from
275 some goofyWh iteheadian, new school, Heideggerian, phenomenological
276 tradition. He has no standing in philosophy. One of my great fears when I first
277 got to the Hastings Center was that some one would take a picture of me standing
278 near him and I would be banned from philosophy forever. (Laughter) So , yes.
279 FOX: So he was revered.
280 CAPLAN: Yes, within bioethics but despised or marginalized within philosophy. Again, to
281 repeat, the philosophical heyday, it's hard to reconstruct this, with Nozick and
282 Rawls and their minions, this was when philosophers were kings. And they are Arthur Caplan Acadia Institut eSt udy of Bio ethics in Am erican So ci ety pag e 15
283 mashing these other people into the ground. Philosophy and Public Affairs is
284 founded at this time, which is a major journal of influence. Nobody even looks at
285 it anymore today, but was very important in its day. Al l the conceptual analysis
286 stuff is booming. Philosophy is hiring, it's thriving. Tom Nagle is a student of
287 this era. Anybody you can thinkof in ethics and political philosophy who's still
288 around today sort of got born as a Rawlsian or a Nozickian. All of them came in
289 contact with one or the other. These are real schools of thought and they are just
290 mashing what went before. Macklin, Gorovitz,Beauchamp , Childress, the people
291 who are institutionalizing the field. The firsttextbo ok, Gorovitz and Macklin's,
292 The Moral Problems of Medicine, is another example of the institutionalization of
293 the philosophical view. The reason you are shaking your head and saying "I can't
294 see it" is because it's buried under the Gorovitz textbook, the Childress and
295 Beauchamp textbook, The Encyclopedia of Philosophy. It's just everywhere and
296 the struggle is, "is this legitimate philosophy?" Who would care today to ask that
297 question? Philosophy isn't strong anymore, no one cares what Gary Hatfield
298 thinks in the philosophy department about bioethics. It's not interesting. But
299 philosophy in its boisterous time--it's coming out of, a period of complete
300 skepticism about the possibility of doing what's called normative ethics, which is
301 guiding behavior with real principles and values. It's been through a meta-ethical
302 debate where the philosophers of science condemned ethics as meaningless. C.L. Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 16
303 Stevenson, a famous Michigan philosopher, has declared that ethics is nothing but
304 emotions. So there isn't any ethics to do. There are just questions to ask about
305 "how do you make sense out of these statements that look like they're supposed to
306 be about ethics but they don't have any content to them?" Rawls and Nozick
307 don't solve this riddle, they just write books that make it irrelevant because people
308 believe them, so to speak. They really never get to the fundamental, metaphysical
309 or epistemological challenges to "how can there be ethics?" In a sense what they
310 do is they say, "Here's how, here's a theory. If you believe this and you believe
311 this, if the veil of ignorance falls and you have rational people and they have
312 resources, you can get to these assumptions about what's fair ... see?"
313 FOX: Are we talking now about the 1970's and 1980's, or just the '80's?
314 CAP LAN: The philosophical revolution is the '70's. Its manifestation is the early '80's, and
315 that's just when bioethics gets captured ...I don't know if it gets captured, you
316 might say it sort of is the natural place where eager people thinking about ethics
317 fall. If they can't get a job in a philosophy department.. ..
318 FOX: That's also coincident with the Reagan-Bush era.
319 CAP LAN: Nozick wins the debate against Rawls.
320 FOX: And does that give bioethics a skew in that direction?
321 CAP LAN: Yes, absolutely! Some of that individualism that I was just moaning about when I
322 came in here comes from that victory. And has left a long victory if you add it to Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 17
323 a place that you know well, the University of Chicago's economics and law... I
324 think it's those two strains that dominate the '80's and make bioethics, in my
325 view, narrow. That's where the autonomy value wins out, it's fromthese deeper
326 intellectual traditions. Autonomy doesn't win out in bioethics just because there
327 are bioethicists arguing for autonomy, it wins out against this broader backdrop.
328 Or those are the things that people find appealing because they hear them in the
329 broader context. In a funny way, Nozick has much to do, I believe, with shaping
330 bioethics, although he'd deny it and say, "What are you, crazy? I don't even care
331 about it!" But he did.
332 FOX: But the political and ideological climate at the time has a great deal to do with it.
333 CAPLAN: Yes, and into this setting it comes.
334 FOX: And although bioethics is not politicized, if you look at it ideologically at least in
335 this period we're talking about, it ends up being very conservative.
336 CAPLAN: Yes, and also not threatening.
337 FOX: Once you start to touch social things and you're in another ballpark, not just
338 epistemologically but ideologically.
339 CAPLAN: Well, you might say that some of the impulses of social ethics, and justice
340 questions, and structural questions about the system that might have been asked in
341 the '60's and early '70's are replaced by individual rights focuses in the 1980's.
342 Also bioethics at that point is not threatening; every medical school would be Arthur Cap lan Acadia Institute St udy of Bioethics in American So ciety page 18
343 proud to have it, it doesn't ask questions about the structure, it asks questions
344 about the bedside. They're finequestions but it doesn't get over to issues like
345 why are we living in a two class medical world, why can't we vaccinate kids? I
346 have a little aside in something I was writing recently that I thought would interest
347 you. It's a question that I think is very telling. Why did bioethics take the
348 competent individual as its paradigm? It could've taken the child. Itcould've
349 taken a retarded person. It could've taken an old senile person. There are a lot of
350 options about what would be the paradigm. The paradigm is picked as the
351 competent adult because that's philosophically what the model is in Rawls and
352 Nozick. The competent, rational, reasoning adult who makes choices under
353 certain assumptions. That is exactly how it got into bioethics. Itis exactly what
354 reifies individual autonomy and liberty discussions. And so the structural
355 questions, if you want to put it this way, fromthe philosophy point of view are
356 lost behind that veil.
357 END OF SIDE ONE, TAPE ONE
358 CAPLAN: Critics fromthe outside had such a hard, hard time getting heard about
359 contextualism or the relevance of social inquiry, setting, context, to bioethics.
360 That sounded a little bit like some of the older strains of religion which
361 philosophy is always hostile to, so it was trying to kill it off because it wanted to
362 be .. .I'm making it sound a little bit like it's an entity that's alive, but you know Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 19
363 what I mean. In the intellectual sense, it's trying to struggle against that and claim
364 control. It's not in tune at all with the philosophical outlook of the day, which is
365 to start with the individual, the competent individual. It's not in tune with the
366 political and social enterprise of the day, which is to buy all this and put it into our
367 politics and into the entire culture, that's what the '80's is all about. And then it's
368 also the least threatening thing because you can certainly go get hired to do it in a
369 medical school and you haven't terrorized the dean by saying you're going to hold
370 demonstrations until they let the poor people in for transplants or something. So
371 that's why you had such a hard time getting heard, I think. It wasn't that people
372 thought that social science was stupid.
373 FOX: It seemed the perspective I had was too religious ...
374 CAPLAN: Right, exactly, this is all wrong.
375 FOX: But on the other hand, you could argue that if bioethics had come to this stage of
376 blossoming, or maturity, or institutionalization in the 1960's rather than the 1980's
377 I don't know what influence the larger political climate would've had as
378 compared to the ....
379 CAPLAN: Might've killed it, I don't know! (Laughter) I mean it is interesting. You could
380 say, don't pick your strongest individual as your paradigm case of how to think
381 about the ethics of health care, think about your most vulnerable one. I just wrote
382 this little chapter about testing and I said, I'm going to pick children and make the Arthur Caplan Acad ia Inst itute St udy of Bioeth ic s in Amer ican So ciety page 20
383 whole analysis about testing children because I thinkthat'll tell us interesting
384 things. I could've said, let's pick the adult. But it comes out all differently, when
385 you pick the kid, they're vulnerable, they're dependent. All these concepts, they
386 can't choose anything, you have to choose for them. That's the Ra wlsian strain
387 and that's the thing that the Nozickian outlook defeats. Rawls' pitch in the end
388 was that fairness requires not making the disadvantaged worse off. And
389 conversely, it's only fair if it makes the worse off, better off.
390 FOX: You're coming into your real professional role now in bioethics and this is the
391 climate. Where are you in this?
392 CAPLAN: I'm struggling with "can you do bioethics and still be a legitimate philosopher?
393 Do I care?'' And something else is going on with me which is, "Gosh, I've
394 learneda lot about clinical medicine, shouldn't I try to forget these bigger issues
395 and maybe focus in instead on some focused problems and see what I can do with
396 them?" And it is transplant that looms up all of a sudden. I would say my
397 personal attention gets pulled away because there are some fightsbreaking out
398 about transplantation just at this time. We're talking early '80's now. One fight
399 that breaks out is "why are rich people coming here and stealing all our organs?"
400 Remember that? Buying our organs, not stealing them, buying them. Another
401 question that comes up is "should we use animals as sources of organs?" This is
402 Baby Fae. Another question that comes up is "should we make mechanical ones Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 21
403 and get away from it?" This is the Jarvick. All of a sudden what happens to me
404 is, I hate to say this about myself, but I think all that work I'd done in science and
405 medicine comes back to, in some sense, save me because I'm the person that starts
406 to get asked about "What is this artificialheart? What's the immunology of
407 transplant? You know about genetics, Art,does it matter if organs are matched
408 closely?" So I'm starting to turninto this sort of resource... pseudo-doc-scientist
409 or something. And I realize I can write on these subjects because no one knows
410 what the hell is going with them! I understand some of this stuff. So I start
411 writing about transplants. I start writing about the artificial heart. Some of that
412 stuffthat you picked up on in your book is stuff fromthat era and then I start to
413 say, "Hey, this is kind of interesting, you might even be able to make some
414 proposals like required request." That's something I start working on at this time.
415 While this deeper philosopher versus other battle is going on, I'm also at Hastings
416 and able to meet legislators who come by and policy people. I start to think, well,
417 I don't know that I care about what the bioethics-philosopher relationship is. I
418 guess what I care about is just taking the problems and doing them. My
419 pragmatism outs. I won't say I was completely indifferent; I did write an article or
420 two. Some of my articles that show up now are about things like "Can Applied
421 Ethics be Effective?" that is considered a little classic from the journal Ethics.
422 and there is another one called, "Mechanics on Duty", which is an attack on sort Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 22
423 of doing sausage grinder style ethical analysis of the Georgetown Beauchamp and
424 Childress type. I'm also starting to get cute with my titles at this time. (Laughter) I
425 did write a number of theoretical pieces about this relationship in which I tried to
426 argue for a pragmatic resolution. I still believe them. They still appear in
427 everything I write since. I haven't changed my mind about any of that but one
428 response is, I do try to address it, I try to write about it.
429 FOX: Aren't you going against the ethos of the field in terms of where your own social
430 sentiments lie?
431 CAPLAN: Yes, I'm definitelymore lefty-liberal. I'm battling, in that sense, against the ethos
432 of the time but I'm also much more pragmatic. I don't care to let the theory hang
433 me up. There are some sneering statements in some of these early articles that say
434 things like, if we're going to have to wait for the right theory then we'll be dead
435 before we do bioethics. So maybe what we could do is agree that there is some
436 mid level problems we could fix and we'll let the bigger theoretical questions
437 work themselves out. It's an appeal to also say, "Look, if a kid can't get rehab
438 post his stroke then he doesn't have to wait for Rawls to win, he just has to get
439 rehab." So there is this driving pitch to say, "Look, pragmatically speaking once
440 you see what the nature of the problems are, they do have focus, they can be
441 resolved because you don't need to go to deep theory to fix them, you can go to
442 mid level things." Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 23
443 FOX: How did that play with Dan Callahan and Will Gaylin and Bob Veatch?
444 CAPLAN: Dan and Bob were, interestingly enough, always more interested in the big theory
445 stuff. I don't think they had that pragmatic turnto them. Dan was always trying
446 to wrestle with his relationship to philosophy. Bob was a theoretician who
447 believed like Rawls that if you had the theory that would be the answer. And he
448 would come up with it. That's what his life has been devoted to; his books and
449 works are devoted to coming up with a theory that links bioethics to the deeper ....
450 FOX: Isn't that a kind of schizophrenic relationship? Because he had friendslike
451 Michael Novak who said that he was supposed to be dealing in theory.
452 CAPLAN: Yes, to tell you the truth. A little aside; Dan would blanch a bit for me to say this
453 but it's true. Dan was never immersed enough in the theory to be able to take on
454 the fight. He knew what the problem was but he didn't have all the moves to
455 make. I also had one other influence working in my favor in this '80's period. I'd
456 been through the history of the philosophy of science wars so I knew that there
457 was a way to bridge this theory-practice problem by just using cases as the
458 paradigm. And I had something that no one else did from the ethics side, I knew
459 that the attempt to have a pure philosophy of science rooted in some theoretical
460 vision, the positivist dream, was collapsing, and the way to keep philosophy of
461 science going was to focus in on actual historical and social cases. And
462 remember, I haven't stopped writing about the philosophy of science even at this Arthur Caplan Acad ia Inst tutei St udy of Bioeth ic s in Amer ican So ciety page 24
463 point...I guess I never have, although no one ever asks me about it. But I had that
464 to hang onto. So part of my move to being pragmatic comes fromthat vision that
465 the way to do the philosophy of science isn't to come up with Camet's theory of
466 confirmationor Popper's theory of falsifiability. It is to take real science
467 behavior, tease out what features seem important and then make some comment
468 about what the logic of science is, which is what the philosophy of science was
469 doing at that time. Th e ethicists didn't have that; ethics was the last home of
470 positivism. It was looking for the true theory. In its heyday during this formative
471 period, it thought, "Rawls and Nozick have got it and you're in one or the other
472 camp." I guess my attitude was in part to say, "This is stupid. There isn't any true
473 theory. Who needs it?'' For most of human problems, particularly at the practical
474 level presented by health care, it doesn't matter, you'll never find yourself divided
475 or stymied by the absence of an overarching theory. What you have to do is
476 identifythe short term value goals that you want to get to and fix them. If you
477 don't have enough organs and you want to preserve a moral framework, you don't
478 want to sell them, you don't want to take them, but maybe you could ask for them
479 more aggressively, that's required request. That's my example of a non-deep
480 theory fix. One other feature I'd mention from this 80's period is I learnedthat if
481 you carve out and area, it's possible to claim expertise over it. And it's probably
482 the case that transplant became my area. I began to write about it, write about it, Arthur Caplan Acadia Institut eSt udy of Bio ethics in Am erican So ci ety pag e25
483 write about it, and then the transplant people began to take it seriously. About the
484 time I'm getting antsy at Hastings, why am I getting nervous? Well, Renee
485 identifiedone ...this is now 1986 that we have come up to; unless I kill Dan I'm
486 not going to move anywhere. (Laughter) I like Dan , so I'm not going to kill him!
487 He seems to want to stay there so, I can't run anything. I can be the associate
488 director, which they made me. But I can't run my own show. And I'm starting to
489 also think that Hastings too is not the best place to be, and not the way to do
490 bioethics, because I'm also startingto become dimly aware of this contextual
491 problem. That it's too purely philosophical. I don't like the individualism
492 emphasis. Plus, I'm missing the clinical focus and talking to patients, which I had
493 when I was at Columbia. All these things are starting to irritate me ...get under my
494 skin, plus I want to run something. So that's when I decided to go to Minnesota.
495 FOX: To go back a minute, what kind of relations did you have with Georgetown during
496 this time?
497 CAPLAN: None. I saw Tom Beauchamp, I saw Jim Childress at Hastings. I only set foot at
498 Georgetown once or twice over the span of seven years. I considered Georgetown
499 a model of how not to do bioethics for another reason : they were a place that
500 basically had set up individual scholars to do their thing. I was enough of a lefty
501 and a communitarian to not think that was the way to bioethics. They are all doing
502 their own thing but not talking to each other; I didn't like that. It never was a pull Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 26
503 to me to want to be there. Bob Veatch, I think, went there precisely because it
504 allowed him to do his own thing. You know, to be fair, Hastings, whatever else it
505 was, was a place that did have a community vision that Dan and Will set for it,
506 that you would talk to each other and that progress would be made in groups.
507 FOX: What was Will's role, because he was outside of the philosophical and the
508 religious... ?
509 CAPLAN: An odd intellectual role. His role was a couple of things. I haven't mentioned him
510 much, but he's important because Will is the first person in a peculiar way to try
511 and take bioethics public. He's my role model, although he'd hate to hear this, for
512 deciding to try to move bioethics into a public arena. But he was doing it a little
513 bit, he's the firstand only person that ever tried. He talked to the newspapers
514 once in a while. He wrote op eds in The New York Times. He wrote that famous
515 article about creating what he called neomorts, for Esquire or The Atlantic. Will
516 was a psychoanalyst. No one knew what the hell he was talking about, from the
517 philosophers. (Laughter) But he did bring this notion that things are not always as
518 they seem. You have to push under the surface to understand. And he tried to
519 introduce that into his work, usually without much serious intellectual response
520 fromtoo many people. He was a very close friend and an important role model to
521 Alex Capron and Leon Kass, he was mentoring them. When they would come to
522 the Center they would spend a lot of time talking with Will. Will was a politician Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 27
523 in the sense in which he could talk to foundation people, he could pitch ideas.
524 Dan stunk at that, he was horrible. He could write the proposal but he couldn't
525 sell the proposal. So Will was kind of the public face of the Center. He also did
526 the first public television series on bioethics. It was a four part show, made with
527 KCTA in Seattle. It was called Hard Choices. That's a public face of bioethics
528 that was produced somewhere around the time I'm finishing at Hastings. I'm
529 going to Minnesota. I've made a conscious decision that one thing that should not
530 happen is, bioethics should not be just academic. And I'm going to try to do
531 something to get public dialogue going about these issues. I don't like the field if
532 it's just an academic thing. Will is the closest thing I have to a role model. Ifl
533 hadn't seen him I never would've thought about it. I wouldn't have even realized
534 it was possible, because out of my academic enculturation it never would've
535 occurred to me.
536 FOX: Did he know Bernie Schoenberg?
537 CAP LAN: I think they did know each other but I don't think they intersected much. Bernie
538 was like the medical school guy and Will was already the psychoanalytic institute
539 guy. They were sort of from different worlds. I never heard them say anything
540 bad about one another but they didn't seem particularly close.
541 FOX: I saw no connection either. So how did Minnesota become a possibility?
542 CAP LAN: It became a possibility because they found me. And they found me because of Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 28
543 transplant. Th e medical school dean and the chief of surgery, Najarian, said,
544 "You write about transplants all the time, we've got the best transplant program
545 out there." They didn't think much of Pittsburgh, they thought that was fullof
546 wild, goofballs. They thought Starzl was a nut, and arguably he is a nut!
547 (Laughter)But Najarian would say, "Look, we're committed to studying, to
548 publishing, to thinking about what we do, we think before we act. So they made
549 this approach and said, "You come here, you do whatever you want, just have a tie
550 to surgery and think about transplant."
551 FOX: What do you think they thought you were going to do?
552 CAPLAN: Provide cover for their transplant activities.
553 FOX: That's sort of what brought you here too, only for genetics. (Laughter)
554 CAPLAN: I had a discussion with the dean. I said, "Look, I'd be happy to come and talk
555 about transplants. What I will tell you is, there is a very good chance that some of
556 what I say you won't like. If you can tolerate it, it will be fine. Moreover, I'm
557 interested in a lot more things than transplants. If you can tolerate that, we'll be
558 fine." He said, "I can tolerate that." Because the dean didn't have the same
559 agenda as the surgery department guy. And in fact, the dean, who's name was
560 David Brown, at the time was a little bit pissed at the surgery department because
561 it was running the entire medical school. So weirdly, the prospect of having
562 somebody that might give some aggravation to the surgery department wasn't so Arthur Capl an Ac adiaInst itute St udy of Bioeth ics in Amer ican So ciety page 29
563 bad, from the dean's point of view. I was politically savvy enough not to say much
564 about that to Najarian. I just said, "Oh, I'm very interested in transplant. I like
565 transplant. I'm happy to do that." So we showed up.
566 FOX: And Dick Simmons was?
567 CAPLAN: His right-hand man. Dick Simmons was actually the intellectual to Najarian's
568 sort of factory model. Simmons is the intellectual of all this. And so I went there
569 and did get immersed in transplant. I learned a lot more about it. I went back into
570 the hospital setting.
571 FOX: Did people think you were nutty to go to Minnesota? Bioethics was not in
572 Minnesota!
573 CAPLAN: Yea, completely crazy. There was nothing there. What I saw as opportunity, they
574 saw as exile or psychotic or something. Plus Jane, my wife, has a teaching job at
575 this point in time. She's a psychologist and she's teaching at Yale. So we've got
576 these two teaching jobs. I can teach at Columbia when I want, I work at the
577 Hastings Center, and now we say we're going to pick up and go to Minnesota.
578 Jane has gotten in cahoots with a team at Carnegie Mellon and they are starting to
579 do productivity studies of scientists. That's what she did for the next ten years,
580 but it turnsinto its own business. They wind up taking it private and it works. So
581 she doesn't care where she is anymore. She decides that she doesn't like
582 academic psychology, it's too academic. She likes the practical, that must be why Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 30
583 we got together. (Laughter) And I see Minnesota as an opportunity to do whatever
584 I want, and hire people. So that was it, that's how we moved. Just as a personal
585 thing too, I'd say we were ready. We'd lived in New York for sixteen years and
586 we'd also just produced Zach. And it seemed like not a great place to raise a kid,
587 New York City. So those were other personal factors that were influential.
588 Minnesota seemed like a nice place to raise a kid. I didn't leave Hastings mad, I
589 leftit happy.
590 FOX: Did they try to keep you?
591 CAPLAN: Yes. Dan was mad though. Dan and I had a falling out that was not ever
592 conscious, but Dan was mad that I didn't hang around to become the director.
593 He's still mad, to this day. He never told me that, but I know he is. (Laughter). I
594 knew it when I talked to him. I knew him so well that I could tell how
595 disappointed he was when I said I was going there. It was like leaving your Irish
596 mother. It never occurred to him that of course I should go to Minnesota. I
597 should go out there and I should run something. Why would you entrust the thing
598 to someone who never ran anything? At the point I left I don't think he felt as
599 invested in anybody as he was in me. Besides that, he and I just got along. For all
600 the times in these interviews I've said things about fighting, or battling, or seeing
601 the world differently, we just personality-wise got along. I don't think we ever had
602 a fightin seven years. I don't think Dan can say that about too many people. I Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 31
603 liked his sense of humor, I liked him, some of his tortured nature appealed to me.
604 I think he liked me because he saw me as sort of rock stable andsomeone he
605 could hang onto at different times ... cheerful. So all that stuff worked.
606 Minnesota turned out to be a very good move. I did, in fact, build up a
607 department andstarted to shape it along the lines that I talked about. One thing
608 that Minnesota became was a Center, where I talked publically a lot about
609 bioethics. People laughed and said, "You're never going to do that from
610 Minnesota, no one will ever hear you. You're not in New York or Washington."
611 But I had an insight; we're living in a world of electronics and satellites andit
612 didn't matter so much, and I was right. They had satellite dishes in Minnesota
613 that could put you on TV. (Laughter) They could beam things on the radio. Th ey
614 had telephones.
615 FOX: So you beganto use the media out there.
616 CAPLAN: Yes, very aggressively there. Consciously, deliberately, intentionally did it. I also
617 began to try to draw people there who had a vision of bioethics that was broader
618 than just philosophy. So I hired Steve Miles, Susan Wolf, Ron Cranford, Rosalie
619 Kane. Rosalie kept hounding me about her interest in nursing homes. I didn't see
620 anynatural way in Minnesota because it didn't have rehab, to get back to that old
621 field. But nursing homes was kind of close, so Rosalie and I began to do some
622 studies. This is where I really began to be interested in the empirical. She said Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 32
623 she was going to do some interviews of nursing home residents to see about their
624 feelings, and what they were in control of , and what they weren't in control of.
625 And I said, "Oh, well that will be fine." And I gave her a list of questions about
626 feeding tubes and advanced directives to ask these older people. On the pilot
627 studies, which I sat in on, the older people kept saying that while they were
628 interested in feeding tubes and advanced directives, they were more interested in
629 what was for breakfast tomorrow morning. It occurred to me that I didn't know
630 what the hell I was talking about. I came here with this whole big framework and
631 I wasn't getting at things that were important to these people. So then I spent a lot
632 of time in the nursing home study. Those became those books that you've seen,
633 Or dinaryEt hics and The Ethics of Case Management, which was a follow up to
634 that. But those studies got me thinking long and hard about how to do empirical
635 work. One other thing took place in Minnesota, I began to do those studies of
636 organ donation behavior. Re quired request went in but there weren't more organs.
637 The surgeons kept saying, "So where are these organs?" I kept saying, "I don't
638 know, people are being asked, if they say no, what the hell do I care!" I actually
639 didn't care if there were more organs. It was just like saying, "Well, you get your
640 chance, if you don't want to do it, you don't do it." But then I began to say,
641 "Well, alright, so why are people saying no so often?" So startedI a very large
642 scale multimillion dollar, unheard of for its time, bioethics study with a crew from Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 33
643 Pittsburgh. Bob Arnold and Laura Siminoff and my student, Beth Vemig, who
644 was a graduate student at Minnesota at that time, now is at Miami. We began to
645 design record and chart reviews, and coordinate a study where nurses would go
646 within 24 hours of a patient death and interview everybody all over the place
647 about what had happened.
648 FOX: Who fundedthat?
649 CAPLAN: That was the AHCPR, the Agency for Health Ca re Policy Research, when they
650 had money. Before the back surgeons killed them by coming out with critical
651 statements about back surgery. Itwas a very important study; it has produced a
652 dozen or more papers, it's like the support study in its way. Again, these are two
653 crucial studies for me because they're different styles of doing research. Rosalee's
654 is qualitative. You interview people in depth and listen to them. You do what
655 we're doing now. You'd sit there with an old lady and she'd tell you about her
656 life and what was important in the nursing home, and who her roommate was.
657 And it took forever to do one interview. The Pittsburgh Organ Donation Study
658 was a forced choice questionnaire with chart reviews looking at thousands of
659 cases. There was no way you could do it as qualitative, it was heavily
660 quantitative. I learned how to do both and that shaped Penn. That's what I was
661 coming to. The Penn vision is coming from Minnesota saying, "B oy, you really do
662 need some understanding of what people think. It is important to see the social Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 34
663 context because you can make changes based on ethics, like required request, that
664 might not work if you don't understand what's really going on out there. We
665 should try to make sure that we study the empirical world as part of what bioethics
666 should be if you really want to effect change, and you want to be responsive to
667 what people's real needs are, you have to have this context." I know the nursing
668 home study for me was a major influence because it reminded me that you can't
669 come with preconceived ideas, but you can come with a moral outlook that
670 changes the kinds of questions you ask. So Rosalie also got something fromme
671 even though I learned that our questions are wrong. She le arned that there are all
672 kinds of nuances and different ways to ask people stuffabout what she would now
673 call autonomy or their quality of life in the nursing home.
674 FOX: That is exactly what most of the bioethicists who are so enthusiastic about
675 ethnography do not understand. What is this moral outlook and how does it shape
676 the questions you ask, is what fascinates me most of all. How is it different from
677 what somebody who is just trained in sociology but not trained ....
678 CAPLAN: I think it really makes a big difference.
679 FOX: I do too, but have you seen anybody writing about that?
680 CAPLAN: No , although I should write up the nursing home study and how it went and
681 evolved, because if you looked at her questionnaire, and you looked at the one we
682 ultimately used, you could see it. It just shiftsover to four senses of autonomy. Arthur Caplan Acadia Institute St udy of Bioethics in American So ciety page 35
683 FOX: You would do a lot of good because I am very, very uneasy about this enthusiasm
684 about everybody rushing in to do qualitative research.
685 CAPLAN: Yea, what do you bring or what do you want? By the time Rosalie and I got done
686 coming back and talking about these people we were talking to I would say, "Now
687 look, there really are four or five senses of privacy. We want to be asking about
688 all of these senses. You can't just ask them questions like, do you care about
689 privacy? That just isn't enough." Are we talking about their bodily privacy, their
690 information privacy, are we talking about privacy in terms of not having to
691 respond to the outside world? I knew all these moves because those were the
692 categories that you'd see. She'd say, "I wonder if they care about being
693 informed?" I'd say, "Informed? You have to ask about competency, you have to
694 ask about do they comprehend?" So the questionnaire moved to reflectthe
695 bioethics categories and pick up stuff and then we recorded it differently. We
696 could say, "Well now, in fact a lot of effort has been made on informing people
697 about living wills." But it turns out what they mean by informed is this, and what
698 the living will means is this, so there's a misplay. Everybody's interested in how
699 you direct the end-of-life care for the elderly. Well, in fact that isn't their number
700 one concernabout what's going on. Their number one concernis how they direct
701 the television set or what chair they sit in. Are these ethical issues? Well, they
702 could be. Arthur Caplan Acadia Institute Study of Bioethics in American Society page 36
703 FOX: Everyday ethics.
704 CAPLAN: Yes, so there's discussions in those books about who gets to sit in the best chair in
705 the sunroom.
706 END OF SIDE TWO, TAPE ONE
707 END OF INTERVIEW